Hospice-Nursing Home Interface, P-00252

HOSPICE –

NURSING HOME

INTERFACE

Guidelines for Care Coordination

for Hospice Patients who Reside in

Nursing Homes

STATE OF WISCONSIN

DEPARTMENT OF HEALTH SERVICES

DIVISION OF QUALITY ASSURANCE

P-00252 (08/2023)

Hospice-Nursing Home Interface Page 2 of 24

P-00252 (08/2023)

TABLE OF CONTENTS

SECTION I – INTRODUCTION AND BACKGROUND ........................................................................... 3

SECTION II – REGULATORY REFERENCES ...................................................................................... 3

SECTION III – CONTRACT CONSIDERATIONS .................................................................................. 4

A. INTRODUCTION ....................................................................................................................... 4

B. REGULATIONS RELATED TO THE HOSPICE / NURSING HOME AGREEMENT ................... 4

1. Contract Requirements .......................................................................................................... 4

2. Hospice Regulations Federal (42 CRF 418.112): ................................................................... 4

3. Hospice Regulations State (DHS 131.30(2)): ......................................................................... 6

4. Nursing Home Regulations Federal (42 CRF 483.70(o)): ....................................................... 6

5. Reimbursement Issues ........................................................................................................... 8

SECTION IV – CLINICAL PROTOCOL DEVELOPMENT .................................................................... 10

A. Priority Areas ............................................................................................................................ 10

Admission Process ....................................................................................................................... 10

Medical Orders ............................................................................................................................. 11

Supplies and Durable Medical Equipment (DME) ......................................................................... 12

Medications .................................................................................................................................. 12

Medical Record Management ...................................................................................................... 13

Hospice Services ......................................................................................................................... 13

Death Event ................................................................................................................................. 15

Quality Assessment Performance Improvement ........................................................................... 15

Emergency Care / Change in Condition ....................................................................................... 15

Employment Issues ...................................................................................................................... 16

B. Patient / Resident Assessment and Plan of Care ...................................................................... 16

Use of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual ........... 18

Patient Change of Conditions ....................................................................................................... 19

Potential Expected Outcomes ...................................................................................................... 19

Expected Outcomes ..................................................................................................................... 21

Special Circumstances ................................................................................................................. 21

SECTION V – GUIDELINES FOR INSERVICE / EDUCATION PLANNING ......................................... 22

Initial Orientation .............................................................................................................................. 22

Ongoing Education .......................................................................................................................... 23

Hospice-Nursing Home Interface Page 3 of 24

P-00252 (08/2023)

SECTION I – INTRODUCTION AND BACKGROUND

Persons who are eligible to access their hospice entitlement have the right to receive those services in

their primary place of residence. For some persons, their chosen “home” is a skilled nursing facility.

This document provides guidelines for hospice and skilled nursing home providers when jointly serving

hospice patients who choose to reside in skilled nursing facilities.

This guideline is not a regulatory requirement, but it is consistent with federal and state regulations if

properly implemented. It is intended as a tool for quality improvement that providers can integrate into

their policies, procedures, and clinical practice. The document is not a “blueprint” for providers. The

guidelines offer a framework to structure joint relationships to promote regulatory compliance and the

mission of both hospice and nursing home providers in service to a common patient and their family at

the end of life.

The Division of Quality Assurance (DQA) would like to thank the Wisconsin Hospice and Palliative Care

Association (WiHPCA) for their collaboration on the content of this guideline.

SECTION II – REGULATORY REFERENCES

Protocols and guidelines outlined in this document were developed with consideration for existing state

and federal regulations.

Wisconsin State Statutes

Chapter 50

, Wisconsin State Statute

Wisconsin Administrative Code

• Chapter DHS 131, Hospices

• Chapter DHS 132, Nursing Home Rules

Federal

• 42 Code of Federal Regulation (CFR) Part 418, Hospice

• 42 CFR Part 483, Medicare and Medicaid; Requirements for Long Term Care Facilities

• Social Security Act Section 1861(dd)

• Centers for Medicare and Medicaid Services (CMS) State Operations Manual, Appendix M,

Hospice Survey Procedures and Interpretive Guidelines

• Centers for Medicare and Medicaid Services (CMS) State Operations Manual, Appendix PP,

Guidance to Surveyors for Long Term Care Facilities

• Centers for Medicare and Medicaid Services (CMS) Long Term Care Resident Assessment

Instrument User’s Manual

Hospice-Nursing Home Interface Page 4 of 24

P-00252 (08/2023)

SECTION III – CONTRACT CONSIDERATIONS

A. INTRODUCTION

The following list of key considerations during hospice/nursing home contract negotiations is

meant to assist providers in effectively coordinating provider services to the hospice patient

receiving routine home care who resides in a nursing home. While by no means all-inclusive,

these factors reflect many provisions found in the hospice and nursing home regulations and

were compiled from comments and guidance distributed by authoritative state (Division of

Quality Assurance) and federal (Centers for Medicare and Medicaid Services) sources.

The information that follows is specifically pertinent to the routine home care (when the resident

is not receiving inpatient, continuous, or inpatient respite care) contract. It is not intended to

comprehensively address considerations for inpatient and respite care, which hospices and

nursing homes may elect to include as part of the same contract or as separate contracts.

Providers are encouraged to review the following contract considerations, but since the listing is

not exhaustive, are cautioned to also review their respective regulations, insurance and liability

concerns, financial position and attorney’s advice prior to entering into any formal contract.

B. REGULATIONS RELATED TO THE HOSPICE / NURSING HOME

AGREEMENT

1. Contract Requirements

Federal Conditions of Participation (§ 42 CFR 418.112) and State of Wisconsin rules and

regulations (DHS 131.30) for hospice have specific requirements related to the written

agreement. Nursing home regulations at 42 CFR 483.70(o) also provide information concerning

nursing home requirements related to hospice services in a nursing home setting.

The agreement specifies the provision of hospice services in the nursing home and must be

signed by authorized representatives of the hospice and the nursing home before the provision

of hospice services. Whether a hospice is allowed access into a nursing home is the decision of

the administrator/owner. While an exclusive or semi-exclusive arrangement can promote

efficiency and safety, providers should avoid illegal inducements in negotiating.

2. Hospice Regulations Federal (42 CRF 418.112):

Written agreement. The hospice and the SNF/NF (Skilled Nursing Facility/Nursing Facility) or

ICF/IID (Intermediate Care Facility for Individuals with Intellectual Disabilities) must have a

written agreement that specifies the provision of hospice services in the facility. The written

agreement must include at least the following:

a. The manner in which the SNF/NF or ICF/IID and the hospice are to communicate with each

other and document such communications to ensure that the needs of patients are

addressed and met 24 hours a day.

b. A provision that the SNF/NF or ICF/IID immediately notifies the hospice if:

a. A significant change in a patient's physical, mental, social, or emotional status

occurs.

b. Clinical complications appear that suggest a need to alter the plan of care.

c. A need to transfer a patient from the SNF/NF or ICF/IID.

d. A patient dies.

Hospice-Nursing Home Interface Page 5 of 24

P-00252 (08/2023)

c. A provision stating that the hospice assumes responsibility for determining the appropriate

course of hospice care, including the determination to change the level of services provided.

d. An agreement that it is the SNF/NF or ICF/IID responsibility to continue to furnish 24-hour

room and board care, meeting the personal care and nursing needs that would have been

provided by the primary caregiver at home at the same level of care provided before hospice

care was elected.

e. An agreement that it is the hospice's responsibility to provide services at the same level and

to the same extent as those services would be provided if the SNF/NF or ICF/IID resident

were in his or her own home.

f. A delineation of the hospice's responsibilities, which include, but are not limited to the

following:

a. Providing medical direction and management of the patient.

b. Nursing and Social Work

c. Counseling (including spiritual, dietary and bereavement).

d. Provision of medical supplies, durable medical equipment and drugs necessary for

the palliation of pain and symptoms associated with the terminal illness and related

conditions.

e. All other hospice services that are necessary for the care of the resident's terminal

illness and related conditions.

g. A provision that the hospice may use the SNF/NF or ICF/IID nursing personnel where

permitted by State law and as specified by the SNF/NF or ICF/IID to assist in the

administration of prescribed therapies included in the plan of care only to the extent that the

hospice would routinely use the services of a hospice patient's family in implementing the

plan of care.

h. A provision stating that the hospice must report all alleged violations involving mistreatment,

neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source,

and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF

or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged

violation.

i. A delineation of the responsibilities of the hospice and the SNF/NF or ICF/IID to provide

bereavement services to SNF/NF or ICF/IID staff.

Hospice plan of care. A written hospice plan of care must be established and maintained in

consultation with the nursing home representative. The hospice plan of care:

a. Must identify the care and services that are needed and specifically identify which provider

is responsible for performing the respective functions that have been agreed upon and

included in the hospice plan of care.

b. Must reflect the participation of the hospice, the nursing home or ICF/IID, and the patient

and family to the extent possible.

c. Any changes in the hospice plan of care must be discussed with the patient or

representative, and nursing home representative, and must be approved by the hospice

before implementation.

Coordination of services. The hospice must:

a. Provide overall coordination of the hospice care of the SNF/NF or ICF/IID resident with

SNF/NF or ICF/IID representatives; and

b. Communicate with the nursing home representatives and other health care providers

participating in the provision of care for the terminal illness and related conditions and other

conditions to ensure quality of care for the patient and family.

Hospice-Nursing Home Interface Page 6 of 24

P-00252 (08/2023)

c. Ensure that the hospice Interdisciplinary Group (IDG) communicates with the nursing home

medical director, the patient's attending physician, and other physicians participating in the

provision of care as needed.

d. Provide the nursing home with the following information:

i. The most recent hospice plan of care specific to each patient

ii. Hospice election form and any advance directives specific to each patient

iii. Physician certification and recertification of the terminal illness specific to each

patient

iv. Names and contact information for hospice personnel involved in hospice care of

each patient

v. Instructions on how to access the hospice's 24-hour on-call system

vi. Hospice medication information specific to each patient

vii. Hospice physician orders specific to each patient

Orientation and training of staff. Hospice staff, in coordination with nursing home facility staff,

must assure orientation of such staff furnishing care to hospice patients in the hospice

philosophy, including hospice policies and procedures regarding methods of comfort, pain

control, symptom management, as well as principles about death and dying, individual

responses to death, patient rights, appropriate forms, and record keeping requirements.

3. Hospice Regulations State (DHS 131.30(2)):

The hospice may contract with other providers for the provision of services to a patient or the

patient's family, or both, in which case the hospice shall retain responsibility for the quality,

availability, safety, effectiveness, documentation and overall coordination of the care provided to

the patient or the patient's family, or both, as directed by the hospice plan of care. The hospice

shall:

a. Ensure that there is continuity of care for the patient or the patient's family, or both, in the

relevant care setting.

b. Be responsible for all services delivered to the patient or the patient's family, or both,

through the contract. The written contract shall include all of the following:

i. Identification of the services to be provided.

ii. Stipulation that services are to be provided only with the authorization of the

hospice and as directed by the hospice plan of care for the patient

iii. The manner in which the contracted services are coordinated and supervised by

the hospice.

iv. The delineation of the roles of the hospice and service provider in the admission

process, assessment, interdisciplinary group meetings and ongoing provision of

palliative and supportive care.

v. A method of evaluation of the effectiveness of those contracted services through

the quality assurance program.

vi. The qualifications of the personnel providing the services.

vii. Evaluate the services provided under a contractual arrangement on an annual

basis.

4. Nursing Home Regulations Federal (42 CRF 483.70(o)):

Hospice Services in Long Term Care (LTC): A LTC facility may do either of the following:

Hospice-Nursing Home Interface Page 7 of 24

P-00252 (08/2023)

a. Arrange for the provision of hospice services through an agreement with one or more

Medicare-certified hospices.

b. Not arrange for the provision of hospice services at the facility through an agreement with a

Medicare-certified hospice and assist the resident in transferring to a facility that will arrange

for the provision of hospice services when a resident requests a transfer.

When hospice care is furnished in an LTC facility through an agreement with a hospice:

the LTC facility must meet the following requirements:

a. Ensure that the hospice services meet professional standards and principles that apply to

individuals providing services in the facility, and to the timeliness of the services.

b. Have a written agreement with the hospice that is signed by an authorized representative of

the hospice and an authorized representative of the LTC facility before hospice care is

furnished to any resident. The written agreement must set out at least the following:

a. The services the hospice will provide.

b. The hospice's responsibilities for determining the appropriate hospice plan of care.

c. The services the LTC facility will continue to provide, based on each resident's

plan of care.

d. A communication process, including how the communication will be documented

between the LTC facility and the hospice provider, to ensure that the needs of the

resident are addressed and met 24 hours per day.

e. A provision that the LTC facility immediately notifies the hospice about the

following:

i. A significant change in the resident's physical, mental, social, or emotional

status.

ii. Clinical complications that suggest a need to alter the plan of care.

iii. A need to transfer the resident from the facility for any condition.

iv. The resident's death.

f. A provision stating that the hospice assumes responsibility for determining the

appropriate course of hospice care, including the determination to change the

level of services provided.

g. An agreement that it is the LTC facility's responsibility to furnish 24-hour room and

board care, meet the resident's personal care and nursing needs in coordination

with the hospice representative, and ensure that the level of care provided is

appropriately based on the individual resident's needs.

h. A delineation of the hospice's responsibilities, including but not limited to:

i. Providing medical direction and management of the patient.

ii. Nursing and Social Work.

iii. Counseling (including spiritual, dietary, and bereavement);

iv. Providing medical supplies, durable medical equipment, and drugs

necessary for the palliation of pain and symptoms associated with the

terminal illness and related conditions.

v. All other hospice services that are necessary for the care of the resident's

terminal illness and related conditions.

i. A provision that when the LTC facility personnel are responsible for the

administration of prescribed therapies, including those therapies determined

appropriate by the hospice and delineated in the hospice plan of care, the LTC

facility personnel may administer the therapies where permitted by State law and

as specified by the LTC facility.

j. A provision stating that the LTC facility must report all alleged violations involving

mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including

injuries of unknown source, and misappropriation of patient property by hospice

Hospice-Nursing Home Interface Page 8 of 24

P-00252 (08/2023)

personnel, to the hospice administrator immediately when the LTC facility

becomes aware of the alleged violation.

k. A delineation of the responsibilities of the hospice and the LTC facility to provide

bereavement services to LTC facility staff.

Designate Member of the LTC Interdisciplinary Team (IDG) to work with hospice

representative: Each LTC facility arranging for the provision of hospice care under a written

agreement must designate a member of the facility's interdisciplinary team who is responsible

for working with hospice representatives to coordinate care to the resident provided by the LTC

facility staff and hospice staff. Responsibilities include:

a. Communicating with hospice representatives and other healthcare providers participating in

the provision of care for the terminal illness, related conditions, and other conditions, to

ensure quality of care for the patient and family.

b. Ensuring that the LTC facility communicates with the hospice medical director, the patient's

attending physician, and other practitioners participating in the provision of care to the

patient as needed to coordinate the hospice care with the medical care provided by other

physicians.

c. Obtaining the following information from the hospice:

i. The most recent hospice plan of care specific to each patient.

ii. Hospice election form.

iii. Physician certification and recertification of the terminal illness specific to each

patient.

iv. Names and contact information for hospice personnel involved in hospice care of

each patient.

v. Instructions on how to access the hospice's 24-hour on-call system.

vi. Hospice medication information specific to each patient.

vii. Hospice physician and attending physician (if any) orders specific to each patient.

viii. Ensuring that the LTC facility staff provides orientation in the policies and

procedures of the facility, including patient rights, appropriate forms, and record

keeping requirements, to hospice staff furnishing care to LTC residents.

Plan of Care. Each LTC facility providing hospice care under a written agreement must ensure

that each resident's written plan of care includes both the most recent hospice plan of care and

a description of the services furnished by the LTC facility to attain or maintain the resident's

highest practicable physical, mental, and psychosocial well-being.

Hospice and End of Life Services Critical Element Pathway CMS-20073 – Please note: The

file ‘CMS-20073 Hospice and End of Life’ is accessible through the ZIP file

Survey Resources –

05/16/2023. Upon downloading the ZIP file, the CMS-20073 file is located within the file folder

LTC Survey Pathways. The file is available in both Adobe PDF and Microsoft Word formats.

5. Reimbursement Issues

Providers must have a clear understanding of the financial ramifications of the partnership. This

discussion should include the following:

 Specify which entity is responsible for billing the cost of specific services and

determining to whom billing is directed. (See Reimbursement Mechanisms Chart.)

 Specify procedure for managing patient’s liability payment when patient’s nursing

home care is covered by Medicaid or Medicaid programs.

Hospice-Nursing Home Interface Page 9 of 24

P-00252 (08/2023)

 Discuss reimbursement surrounding the issues of bed-hold, discrepancies in

payment to the hospice by Medicaid.

 Hospice is responsible for making the decision as to the level of care required and

subsequent arrangements for the resident to receive the care.

REIMBURSEMENT MECHANISMS FOR HOSPICE CARE PROVIDED IN A NURSING HOME

The following chart briefly summarizes various reimbursement mechanisms for hospice care provided in a nursing home.

Medicaid

Medicaid Programs

(Family Care,

Partnership)

Reimbursement

Medicare/Medicaid

(Dual Entitlement)

Medicare

Private Pay /

Insurance

Medicaid (T19) pays

hospice rate for routine

home care plus room

and board at 95% of

nursing home’s Medicaid

rate.

A hospice may

reimburse up to 100% of

the rate the nursing

home would have

received.

The patient/resident

remains responsible for

liability payment.

Hospice reimburses

nursing home in

accordance with

contract. (Note:

Hospice may contract

with nursing home for

services covered by

hospice; e.g., supplies,

pharmacy, OT, PT, ST)

Medicaid will pay bed-

hold for 15 days for a

T19 nursing home

resident while in the

hospital if the nursing

home meets minimum

occupancy

requirements. Medicare

does not pay for bed-

hold.**

Medicaid programs

generally pay for

routine home care

plus room and board.

The reimbursement

rate may vary by

program and county.

Nursing homes bill

Family Care directly

for room and board.

A hospice may

reimburse the nursing

home the difference

between the

Medicaid program

reimbursement up to

100% of the rate the

nursing home would

have received.

Medicare (T18) pays

hospice rate for routine

home care.

T19 pays hospice at 95%

of the nursing home’s

Medicaid rate.

A hospice may reimburse

up to 100% of the rate the

nursing home would have

received.

The patient/resident

remains responsible for

liability payment.

Hospice reimburses

nursing home in

accordance with contract.

(Note: Hospice may

contract with nursing

home for services

covered by hospice; e.g.,

supplies, pharmacy, OT,

PT, ST)

Medicaid will pay bed-

hold for 15 days for a T19

nursing home resident

while in the hospital if the

nursing home meets

minimum occupancy

requirements. Medicare

does not pay for bed-

hold.**

Patient must either

elect the Medicare

hospice benefit

(Medicare pays

hospice routine

home care; nursing

home bills patient

or private

insurance) or

maintain Medicare

Part A coverage for

SNF.*

Nursing home bills

Medicare for SNF

stay. Hospice may

provide service and

bill patient or

private insurance

but cannot

simultaneously

provide free care

as this is seen as

an inducement for

referral.

Nursing home bills

patient or private

insurance. Hospice

bills patient or

private insurance.

A nursing home

resident who does

not meet the

Medicare hospice

benefit criteria may

receive palliative

care in a nursing

home. The hospice

bills the patient or

private insurance.

* In rare cases, if it can be demonstrated that skilled nursing care as defined by Medicare is needed for care not related to the

terminal illness, Medicare Part A will pay for nursing home care under normal Part A Medicare and Hospice services under

the Medicare Hospice Benefit. In this section, SNF is used to distinguish a resident who is receiving care under the Medicare

Part A Nursing Home Benefit.

** Refer to DHS 107.09(4)(j)

Hospice-Nursing Home Interface Page 10 of 24

P-00252 (08/2023)

SECTION IV – CLINICAL PROTOCOL DEVELOPMENT

Effective coordination of care that assures patient needs and regulatory requirements are met

necessitates careful planning by both the nursing home and the hospice. The development of policies

and protocols that define care coordination issues is essential to ensure consistent quality.

A. Priority Areas

Priority areas have been identified for consideration in the development of clinical protocols.

 Admission Process

 Medical Orders

 Supplies and DME

 Medications

 Medical Record Management

 Hospice Core Services

 Death Event

 Quality Assessment / Performance Improvement (QAPI)

 Emergency Care / Change in Condition

 Employment Issues

Admission Process

Protocols should be developed that clarify the admission process. In all cases, the hospice

determines eligibility for hospice admission and the nursing home determines eligibility for

nursing home admission.

Admission: Referral of Nursing Home Resident to Hospice

 Referral of resident to Hospice made by nursing home or others

 Consult / information provided by Hospice

 Patient / resident meets hospice admission criteria and elects to receive hospice care.

Hospice inter-disciplinary group (hospice team) conducts assessments and

collaborates with the physician for any change in orders.

 If a current nursing home resident elects hospice, the nursing home must complete a

significant change in status assessment which requires a new comprehensive

assessment using the resident assessment instrument (RAI). A significant change

must be performed regardless of whether an assessment was recently conducted on

the resident. This is to ensure that a coordinated plan of care between the hospice

and nursing home is in place. Refer to Chapter 2, pages 2-20, of the “Long Term Care

(LTC) Resident Assessment Instrument User’s Manual 3.0” related to significant

change in status assessments.

Hospice-Nursing Home Interface Page 11 of 24

P-00252 (08/2023)

Admission: Referral of Hospice Patient to Nursing Home

 Hospice makes referral to nursing home; the hospice may initiate contact with the

nursing home and facilitates communication between the patient / family and the

nursing home representative.

 Hospice and the nursing home coordinate securing required admission paperwork

(i.e., history and physical, TB screening, physician orders, etc.)

 Transfer of patient to nursing home; the provision of hospice services continues in the

nursing home on day of transfer.

 RAI process and subsequent care plan developed by nursing home / hospice

Admission: Simultaneous Referral to Nursing Home and Hospice

 Referrals made to hospice and nursing home

 Hospice and nursing home coordinate the admission process and required paperwork.

 Hospice services may begin on day of admission to nursing home.

 Initiation of the RAI process, assessments, and care planning process by the nursing

home and the hospice

Medical Orders

 Orders should be consistent with the hospice philosophy and in line with the patient’s

goals and plan of care.

 At the time each hospice patient/resident is admitted to the nursing home, a

decision is made as to the role of the hospice physician, nursing home physician,

and attending physician, if any.

 Specify a procedure for the prompt and orderly communication of general

information, MD orders, etc., between the providers.

 Hospice nurse has the authority to communicate the order(s) to the nursing home

nurse. Nursing home nurse has the authority to communicate the order(s) to the

hospice nurse.

 Clarification of the process of obtaining and implementing orders is defined. Both

providers may document orders. Orders are to be dated and signed in

accordance with Wisconsin laws.

 Both providers do not need to obtain a physician signature for an order. Once an

order is signed, the other provider may copy the order for their medical record.

 Individualized orders for symptom management are obtained by the hospice and

provided to the nursing home. These orders are initiated by the hospice according to

patient need and as identified in the comprehensive plan of care.

 Nursing home patient specific standing orders may be utilized, if hospice determines

that the orders are consistent with the hospice philosophy and the order is specified on

the plan of care.

Hospice-Nursing Home Interface Page 12 of 24

P-00252 (08/2023)

 In the event the nursing home receives new orders or changes to orders, the nursing

home will coordinate implementation of the orders with hospice.

 All orders, including medication, laboratory tests, and other diagnostic procedures

related to terminal illness, must be pre-approved by hospice and specified on the plan

of care.

 The nursing home coordinates the scheduling of routine physician visits (and/or

physician extender visits) that relate to nursing home regulations. Under state and

federal law applicable to nursing homes, a physician extender (e.g., nurse practitioner

or physician assistant) may be utilized after the first 30 days and every 60 days

thereafter.

Supplies and Durable Medical Equipment (DME)

Supplies and DME related to the management of the terminal illness are the responsibility of the

hospice. The nursing home and hospice should coordinate obtaining and monitoring supplies

and services according to the terms of their contract. Routine DME and supplies are provided

by the nursing home as part of room and board. A current list of what is included in room and

board can be found at:

https://www.forwardhealth.wi.gov/WIPortal/Subsystem/KW/Print.aspx?ia=1&p=1&sa=40&s=5&c

=30&nt=

DME and supplies not covered in the room and board payment which is related to the terminal

illness is the financial responsibility of the hospice.

 A hospice may contract with a nursing home for non-routine DME if the nursing home

meets the hospice state and federal regulations related to provision of DME.

 Disposable medical supplies related to the terminal illness, as specified in the plan of

care.

Medications

 Administration of medications is the responsibility of the nursing home and is included

in the room and board payment.

 Prescription medications related to the terminal illness (medications supplied by

hospice) must meet nursing home pharmacy labeling and distribution requirements.

 The hospice is responsible for assessing the need for and obtaining medications

related to the terminal illness in a timely manner.

 Medications related to the terminal illness are billed to the hospice provider, even if the

resident has Medicare Part D coverage.

 The nursing home is responsible for accounting for medications and ensuring access

to emergency medications.

 For hospice residents in pain, providers must coordinate their care including:

Hospice-Nursing Home Interface Page 13 of 24

P-00252 (08/2023)

 Choice of palliative interventions

 Responsibility for assessing pain

 Responsibility for monitoring symptoms of pain and adverse reactions

 Modifying interventions as needed

Medical Record Management

• Copies of hospice informed consent, Medicare Hospice Benefit election, current

physician certification and recertifications, advance directives, plan of care,

medications, and physicians orders must be on the nursing home chart.

• Providers mutually agree upon a system to store and share documents in the medical

record. If the medical records are maintained in notebooks, combining documents in

the same notebook separated by a hospice tab may facilitate the communication of

information.

• Documents provided by the hospice, such as election forms, advance directives,

certification of terminal illness, and any subsequent re-certifications of terminal illness

should remain in the nursing home medical record and not be thinned.

• Original MDS information stays with nursing home record and may be utilized by the

hospice.

• The patient’s record in the nursing home will confidentially identify the person as a

hospice patient.

• The records of a patient residing in the nursing home must include clinical information

that is relevant to the care of the patient (orders, data assessment, etc.), whether

obtained by the hospice or the nursing home.

Hospice Services

Hospice services are defined in the Code of Federal Regulation (CFR) and include nursing

services, medical social services, physician services, medical director, and counseling services.

These services are to be routinely provided directly by hospice employees and cannot be

delegated to the nursing home staff. All covered hospice services must be available as

necessary to meet the needs of the patient for the terminal illness and related conditions.

Additional hospice services include aides and volunteers.

a. Nursing Services

Nursing care is a core service of hospice for assessment, planning, intervention, and

evaluation.

The hospice may involve nursing personnel from the nursing home to assist with the

administration of prescribed interventions as specified in the plan of care. This

involvement would be to the extent that the hospice would routinely utilize the patient’s

family/caregiver in implementing the plan of care.

b. Medical Social Services

Hospice-Nursing Home Interface Page 14 of 24

P-00252 (08/2023)

Social services constitute a core service of hospice for assessment, planning,

intervention, and evaluation related to the terminal illness.

Other social service interventions may be provided collaboratively by hospice and

nursing home social workers based on the plan of care.

c. Counseling Services (Bereavement / Dietary / Spiritual / Other)

Counseling is a core service of hospice for assessment, planning, intervention, and

evaluation related to the terminal illness (type of counseling is defined by individual

hospice).

Bereavement services are a required service for licensure per DHS 131.25(6)(a),

Wisconsin Administrative Code. Bereavement counseling is extended to other

residents of the nursing home as identified in the bereavement plan of care.

Additional counseling interventions may be provided collaboratively by the hospice and

nursing home staff based on the plan of care.

d. Physician Services

Physician Services are a core service of hospice for assessment, planning, intervention,

and evaluation related to the terminal illness.

At the time of admission to hospice, a decision is made as to the role of all physicians

providing care. Attending physician services may be provided by the hospice or nursing

home medical director, the patient’s attending physician, or their designees. The patient

has the right to choose her/his attending physician.

Consulting physicians may be involved. Coverage for attending physicians is provided

by consulting physicians. The hospice is responsible for arranging consulting physician

services.

e. Therapy Services

Therapy services (physical therapy, occupational therapy, and speech-language

pathology) should be made available based on patient need and as specified in the plan

of care. Provision of contracted services, such as physical therapy, occupational

therapy, speech therapy, etc. related to the terminal illness, should be specified on the

plan of care and clarified in the contract.

f. Hospice Aide Services

Aide services should be provided collaboratively by the hospice and nursing home

based on patient need and as specified in the plan of care. The nursing home is

responsible for providing hospice patients the same level of services provided to non-

hospice residents. (Reference “Nursing Home Surveyor Protocols, Appendix PP.”) The

hospice is responsible for providing nursing home patients the same level of services

provided to hospice patients in their own homes. Hospice aides must have successfully

completed hospice orientation addressing the needs and concerns of residents and

families coping with a terminal illness.

g. Hospice Volunteer Services

Volunteers may be asked to provide patient care services. The service will be identified

by the hospice RN and noted in the patient’s plan of care. Volunteers are considered

Hospice-Nursing Home Interface Page 15 of 24

P-00252 (08/2023)

hospice employees and will receive a background review, training, and orientation in

hospice and nursing home prior to any patient care.

Death Event

Death is an anticipated event for the hospice patient. Protocols should be established to define

mutual responsibilities at the time of death:

• At the time of death, the nursing home must notify the hospice. The hospice RN is

legally authorized to pronounce death and is responsible for coordinating the death

pronouncement and subsequent interventions, including coordination with the family

and funeral home or coroner, if indicated.

• Review state, county, and nursing home guidelines regarding coroner/medical

examiner involvement, and follow the protocol.

• The hospice nurse coordinates notification of physician for release of body.

• Medication disposal is the responsibility of the nursing home.

• Specify hospice and nursing home role in supporting the resident’s family/caregivers

and nursing home staff.

Quality Assessment Performance Improvement

The nursing home and hospice are required to implement quality assurance/performance

improvement activities per respective regulations.

A collaborative approach to problem solving and outcome monitoring is encouraged for inter-

related issues.

Emergency Care / Change in Condition

Emergency care is defined as unexpected and may or may not be related to the terminal illness.

Care should be consistent with the patient’s stated wishes in the advance directive and with the

physician’s orders, including cardiopulmonary resuscitation.

Nursing home staff provides immediate care in conjunction with nursing home policy and/or

based on plan of care.

Nursing home staff must notify hospice immediately of patient change of condition for further

assessment and revision of plan of care as specified in the contract.

Nursing home staff immediately notifies the hospice if:

 A significant change in a patient’s physical, mental, social, or emotional status occurs;

 Clinical complications appear that suggest a need to alter the plan of care;

 A need to transfer a patient from the nursing home arises and the hospice makes

arrangements for, and remains responsible for, any necessary continuous care or

inpatient care necessary related to the terminal illness and related conditions; or

Hospice-Nursing Home Interface Page 16 of 24

P-00252 (08/2023)

 A patient dies.

Hospice is responsible for making the decision as to the level of care required and subsequent

arrangements for the resident to receive the care, medications, or equipment, if needed, related

to the terminal illness.

Employment Issues

 A key consideration for both the hospice and nursing home is the extent to which

services will be directly provided by hospice with its own staff, since hospice receives

the payment.

 A hospice may use contracted employees for core service only during:

 Periods of peak patient load

 Extraordinary circumstances

 For a hospice, “employee” is defined in 42 CFR 418.3 and DHS 131.13(7) and (25).

These definitions also apply to hospice volunteers.

 Nursing home employees may be employed by or volunteer for a hospice during non-

nursing home employment hours. The hospice will ensure:

 Accurate time records and wage and hour compliance

 The hospice employee or volunteer will provide care and services only to hospice

patients

 Clear delineation of responsibilities to avoid allegations of dual reimbursement or

inducement of referrals

 The hospice and nursing home will ensure that all state and federal employment

regulations are met. Individual employer records will be kept by each entity and

shared with the other entity as specified in the contract.

 Specify orientation and on-going training requirements.

 Criminal background checks will be completed per contract.

B. Patient / Resident Assessment and Plan of Care

The nursing home and hospice must develop a coordinated plan of care for each patient that

guides both providers. The coordinated plan of care must identify which provider (hospice or

nursing home) is responsible for performing a specific service. The coordinated plan of care

may be divided into two portions, one of which is maintained by the nursing home and the other

by the hospice. Based on the shared communication between providers, both providers’ portion

of the plan of care should reflect the identification of:

 A common problem list;

 Palliative interventions;

 Palliative outcomes;

 Responsible discipline;

Hospice-Nursing Home Interface Page 17 of 24

P-00252 (08/2023)

 Responsible provider; and

 Patient goals

When a patient is admitted, both providers are responsible for establishing their portion of the

plan of care based on their regulations.

 The hospice interdisciplinary group (IDG) establishes and maintains the plan of care for

hospice service for the terminal illness and related conditions in consultation with nursing

home staff, the attending physician (if any), and the patient or representative.

 The nursing home may use the hospice IDG’s assessment of the resident in completing the

required Minimum Data Set (MDS) for nursing home residents and completing the nursing

home portion of the plan of care. The nursing home is responsible to assure that the MDS

is complete and submitted in accordance with the nursing home requirements.

The nursing home is required to update its plan of care in accordance with any federal, state, or

local laws and regulations governing the particular nursing home and the hospice is then

responsible for updating the plan with the nursing home, the attending physician and patient or

representative (to the extent possible) as frequently as the patient’s condition requires, but no

less frequently than every 15 calendar days per federal hospice regulation 42 CFR 418.54(d)

 The providers must have a process in which they can exchange information from the

hospice IDG plan of care reviews and assessment updates and the nursing home team,

patient, and family (to the extent possible) conferences, when updating the plan of care and

evaluating outcomes of care to assure that the patient receives the necessary care and

services.

The provision of care by each provider for the resident and their family is based on the

coordinated plan of care. The care, treatment, and services by either provider related to the

terminal illness and related conditions must be provided based on the hospice portion of the

coordinated plan of care.

 Hospice may involve nursing home nursing personnel in the administration of prescribed

therapies, as they would use the patient’s family/caregiver in implementing the plan of care.

Hospice remains responsible for arranging, providing, and ensuring availability for patient

use of medications or other interventions for symptom control, medical supplies or DME

related to the terminal illness. The hospice’s care includes the provision of the respective

functions that have been agreed upon and included in the hospice portion of the coordinated

plan of care as the responsibility for hospice to perform.

 The nursing home remains responsible for arranging, providing, and ensuring for patient use

of the medications, medical supplies, and/or DME not related to the terminal illness and

related conditions. The nursing home’s care includes the provision of the respective

functions that have been agreed upon and included in the hospice portion of the coordinated

plan of care as the responsibility for the nursing home to perform.

The providers must have a procedure that clearly outlines the chain of communication between

the hospice and nursing home in the event a crisis or emergency develops, a change of

condition occurs, and/or changes to the hospice portion of the plan of care are indicated.

Hospice-Nursing Home Interface Page 18 of 24

P-00252 (08/2023)

Use of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI)

Manual

General Framework for Decision-Making

Nursing homes are required to use the Resident Assessment Instrument (RAI) that includes the

Minimum Data Set (MDS) for all nursing home residents, including residents who choose

hospice. The MDS is completed at the time of admission and periodically throughout a

resident’s stay. A new comprehensive assessment is required when there is a significant

change in status that meets the definition in the RAI. A significant change in status assessment

(SCSA) is required to be performed when a terminally ill resident enrolls or discontinues

hospices and remains a resident at the nursing home.

• Recommendation 1

The initial RAI is very important and includes the MDS, as well as the periodic

reviews. Sharing of information and collaborating in this process is strongly

encouraged. It is essential that the hospice core team and the nursing home staff

both derive patient care decisions from the same core set of patient data.

Many of the patient-change criteria that can trigger the need for generation of a new MDS

for terminally ill or dying patients are, in fact, changes that are a natural, expected outcome

of the progression of a terminal illness and/or the dying process. The key in determining if a

SCSA is required for individuals with a terminal condition is whether or not the change in

condition is an expected, well-defined part of the disease course and is consequently being

addressed as part of the overall plan of care for the individual. In these situations, the

patient care benefits of generating a new MDS are minimal at best and are far outweighed

by the intrusion to the patient that the process of developing a new MDS entails.

• Recommendation 2

If a terminally ill resident experiences a new onset of symptoms or a condition that is not part

of the expected course of deterioration and the criteria are met for a SCSA, a new

assessment is required. Periodic reviews (quarterly and annually) are still required.

Illustrated as a process, this statement would look as follows:

Trigger Change in Patient Condition (after hospice election).

Notify and Review

The nursing home reports the change to hospice and initiates a

joint review of the Care Area Assessments (CAA).

Decision

The hospice and nursing home staff make a two-fold determination: (a) Is

the change in condition related to the progression of the terminal illness?

(b) Was the change already anticipated and documented on the MDS?

Action

If “yes,” to both questions:

No new comprehensive assessment; hospice and nursing

home staff address changes through the plan of care.

If “no,” to one or both questions:

New comprehensive assessment by the nursing home staff

and hospice is completed to determine changes to the care plan.

Hospice-Nursing Home Interface Page 19 of 24

P-00252 (08/2023)

Patient Change of Conditions

Various elements of the nursing home MDS/RAI relate to the progression of the terminal illness

and/or dying process. When supported by hospice philosophy and experience, elements

subject to a change in condition are divided into three categories, detailed below. Guidelines to

govern the decision-making process for determination of whether a new MDS is to be generated

are outlined in the following chart.

Category Problem Area

Potential Expected Outcomes

of the Progression of the Terminal

Illness and/or Dying Process

• Delirium

• Use of Psychotropic Drugs

• Pressure Ulcers

• Dental Care

• Urinary Incontinence (including catheter)

• Behavior Problems

• Falls (patient at risk for)

• Cognitive Loss/Dementia

• Communication

• Pain

Expected Outcome

of the Progression of Terminal Illness

and/or Dying Process

• Dehydration and Fluid Maintenance

• Psychosocial Changes

• Activities of Daily Living (ADL)

• Mood Status

• Activities

• Nutritional Status

• Visual Function

Special Circumstances

• Physical Restraints

• Feeding Tubes

• Return to Community

Potential Expected Outcomes

Certain changes in patient condition are potential, expected outcomes of the progression of the

terminal illness and/or dying process. While they may not be present in every terminally ill or

dying patient, these changes are not unexpected and are routinely addressed by hospice staff

in the regular course of care. The occurrence of one of these changes should not trigger a

change of condition MDS, if the change is related to the terminal illness and/or dying processes,

is anticipated, and is documented.

In evaluating the change of condition, the elements of the change should be reviewed by the

nursing home staff with the hospice staff. This process will necessarily involve the expertise of

the nursing home staff and underscores the importance of the review being a joint effort. The

focus of the review is based on the resident’s condition regardless of the cause.

Hospice-Nursing Home Interface Page 20 of 24

P-00252 (08/2023)

The following grid provides sample statements that include elements to be reviewed under each

Care Area Assessment (CAA) listed. Additional elements should be included based on an

assessment of individual patient circumstances.

Care Area

Assessment (CAA)

Elements of Review

Delirium Assess medication, psychosocial state, and sensory loss.

Use of

Psychotropic Drugs

• Assess medications (drug review) and side effects.

• Adjuvant drug therapy will be utilized to provide palliative symptom

management.

• The risk-benefit ratio evaluation regarding drug initiation and

continued use, including use outside the guidelines, will be

assessed by the hospice IDT / IDG and nursing home staff.

• Documentation will be recorded in the clinical record by nursing

home staff.

• Reference P-00336, Informed Consent Requirement in Nursing

Homes. More information can be found at:

https://www.dhs.wisconsin.gov/regulations/nh/faq-infconsent.htm

Pressure Ulcers

• Assess pressure versus statis ulcer.

• Assess skin integrity.

Dental Care

• Dental care to increase comfort may be undertaken.

• Preventative dental care is not an expected part of the plan

of care.

Urinary Continence

(including catheter)

• Reduced output may occur given the progression of the terminal

illness and dying process.

• Assess UTI, fecal impaction, UA, diabetes, medication.

Behavior Problems

Assess volatility of mood, medications, and cognitive status.

Falls

(patient at risk for)

• Safety issues can be anticipated because of physical deterioration

with a terminal illness and associated adjuvant drug therapy.

• Assess medications, appliances, and environment.

Cognitive Loss /

Dementia

Assess functional limitations, sensory impairment, medication

involvement factors, and failure to thrive.

Communication

Assess components of communication, including strengths and

weaknesses and medication.

Pain

Assess whether the resident is on a scheduled pain medication that

controls discomfort as reported by the resident.

Terms

• IDT = Interdisciplinary Team

• IDG = Interdisciplinary Group

• UA = Urinalysis

• UTI = Urinary Tract Infection

Hospice-Nursing Home Interface Page 21 of 24

P-00252 (08/2023)

Expected Outcomes

Certain changes in patient condition are expected outcomes with a high probability of occurring

as part of the progression of the terminal illness and/or dying process. There are no identifiable

benefits of triggering a change-of-condition MDS on these criteria, provided that the hospice and

nursing home staffs have (1) jointly reviewed the criteria and determined that the change of

condition is linked to the terminal illness and/or dying process and (2) this review and

determination have been documented in the clinical records.

Seven of the CAA problem areas are expected outcomes of the progression of the terminal

illness and/or dying process. The following sample statements address the respective CAA

problem area listed.

 Dehydration and Fluid Maintenance. Changes in hydration status and fluid balance

may occur as part of the progression of the terminal illness and/or dying process.

 Psychosocial Changes. Changes in lifestyle and interactions may occur as part of the

progression of the terminal illness and/or dying process.

 Activities of Daily Living (ADL). The hospice patient residing in the nursing home may

become increasingly dependent on assistance with his or her activities of daily living as

part of the progression of the terminal illness and/or dying process.

 Mood States. The person experiencing a terminal illness, from diagnosis to death, is

anticipated to have emotional fluctuations.

 Activities. A decrease in or non-involvement in activities is an expected outcome of the

progression of the terminal illness and/or dying process.

 Nutritional Status. Declining nutritional status with progressive weight loss may be

expected in a terminal illness.

 Sensory Functions. A decrease in sensory function may occur as part of the terminal

illness and dying process.

Special Circumstances

Changes in patient condition that present the potential need for feeding tubes or physical

restraints warrant special consideration. These interventions may have potential expected

outcomes when utilized for residents with progression of the terminal illness and/or dying

process; and they are of such a nature as to merit different elements of review.

• Physical Restraints. Physical restraints, of the least restrictive type, appropriate to the

resident, may be used only under the order of a physician. If used, the restraint must

enable the resident to maintain his or her highest level of functioning. Restraint usage

must be consistent with the guidelines set forth in the CMS State Operations Manual and

state/federal nursing home/hospice regulations.

• Feeding Tubes. A normal part of the dying process is the body’s decreased need and

the patient’s decreased desire for nutrition and hydration. The hospice is responsible for

discussing the use of feeding tubes with the patient/family as the terminal illness

Hospice-Nursing Home Interface Page 22 of 24

P-00252 (08/2023)

progresses and will initiate enteral/parenteral feeding at patient/family request, as

consistent with the philosophy of the individual hospice. Nursing home staff is involved

to the extent that the hospice would routinely utilize the patient’s family/caregiver in the

provision of enteral/parenteral feedings.

 Return to Community. Occasionally a resident may have the desire to die in his/her

private home. This requires coordination to assure that the resident has enough support

to meet their needs and those of the caregiver. Hospice is responsible for making the

transfer arrangements in collaboration with the nursing home.

SECTION V – GUIDELINES FOR INSERVICE / EDUCATION PLANNING

Clear communication of the basic components of the contract, the policies and protocols that guide

care coordination, and understanding the key regulations that govern both providers is essential for a

successful nursing home/hospice partnership. Achieving quality outcomes for patients and their

families should be the focus of all staff efforts.

Assuring effective participation by all levels of staff requires careful planning of the initial orientation

following the establishment of a contract. Ongoing educational efforts aimed at improving the efficiency

and understanding of experienced and new staff is also essential.

It is the hospice’s responsibility to assess the need for hospice employee training and coordinate their

staff training with representatives of the facility. It is also the hospice’s responsibility to determine how

frequently training needs to be offered in order to ensure that the facility staff furnishing care to hospice

patients are oriented to the philosophy of hospice care. Facility staff turnover rates should be a

consideration in determining training frequency.

Suggested content for these educational efforts are separated into “Initial Orientation” and “Ongoing

Education.”

Initial Orientation

Introducing the hospice concept to nursing home staff may be most effectively accomplished

by using an interdisciplinary approach. Representation from each of the core disciplines is ideal to

establish trusting relationships and encourage professional interaction. Recommendations for

inclusion in the initial orientation process are listed below.

Note: It may be useful to group the topic areas according to individual roles of nursing home staff

(i.e., meeting with business office and clerical staff separately from direct patient care staff to allow

for questions and discussion specific to the expertise of the group).

• Discussion of hospice concept and philosophy, including patient’s entitlement

• Informed consent and corresponding expectations/accountabilities

• Services available; delineation of benefits

• Introduction of core team members/roles

• Introduction and discussion on the use of hospice volunteers

• Terminology; definition of terms as specified in the contract

Hospice-Nursing Home Interface Page 23 of 24

P-00252 (08/2023)

• How/when to notify hospice

• On call availability

• Discussion of mutual roles and responsibilities as outlined in the contract

• Communication and collaboration relating to care planning, ongoing patient needs, family

support, and record maintenance

• Symptom management practices common for hospice patients

• Securing and processing of physician orders (including utilization of standing orders, if

applicable)

• Reimbursement scenarios

• Bereavement services available

• Location of resource materials, such as a hospice manual with accompanying quick

references

• DME, disposable supplies, oxygen, and ancillary services to be supplied by the hospice

• Provision of pharmacy services

Clarifying the role of the hospice team in the nursing home needs to be balanced by a

corresponding effort to educate hospice staff on the regulations and protocols of the nursing home.

Information to be included in this effort might include the following:

• Tour of the facility, with introductions of key personnel, location of records, security system

operation, and any information specific to the physical layout and daily routine.

• Reporting procedures when entering or leaving the nursing home

• Discussion of resident rights

• Life Safety Code, including fire/emergency procedures, exits, etc.

• Key terminology; definition of terms, including terms specified in the contract

• Comprehensive assessment process and requirements

• Care planning process, including conferences, family involvement, etc.

• Record keeping practices, including documentation and access to electronic records

• Infection control issues, especially including biohazard waste disposal, location of personal

protective equipment and blood spill clean-up kit, etc.

• Chemical/physical restraints

• Medication management, including regulations governing use of psychotropic, “unnecessary

medications,” self-medication, etc.

• Patient level of care reimbursement scenarios

• Pertinent facility policies (i.e., CPR, hydration, RN coverage, any policies that explore ethical

issues)

Ongoing Education

Many hospices provide updates for their contracted nursing homes to review practical issues

related to mutual roles and responsibilities. This provides an opportunity for dialogue, problem

Hospice-Nursing Home Interface Page 24 of 24

P-00252 (08/2023)

solving, feedback, and recognition of the cooperative relationships and the impact this collaboration

has on quality care for patient. Likewise, nursing homes may want to provide similar opportunities

for hospice staff to share current trends and industry standards. Suggested topics for these

periodic updates include:

 Pain control and other symptom management protocols commonly used for hospice patients

• Loss, grief, and bereavement care

• Quality assurance/performance improvement study results and recommendations

• Practical issues related to communication with physicians, management of orders, etc.

• Care plan coordination processes

• Volunteer involvement and utilization

• Review and discuss mutual roles and responsibilities, as appropriate

Some hospices hold regular conferences in the nursing home on a prearranged schedule to

communicate patient related issues. Others conduct occasional IDG meetings in the nursing home

and encourage nursing home staff participation.

These suggestions, as well as the guidelines for initial orientation, are not intended to be all-

inclusive. Creative approaches that foster improved understanding and communication between

the nursing home and hospice providers are encouraged. The use of various “mediums” is helpful

to have available in the nursing home for staff who are unable to attend scheduled in-services.

These might include audio/video tapes, self-learning modules, quick reference materials, and a

manual containing pertinent hospice protocols/policies.